Campbell v. GA Dept. of Corrections , 169 F.3d 1353 ( 1999 )

Kimberly CAMPBELL, Plaintiff-Appellant,
v.
James SIKES, et al., Defendants-Appellees.
No. 98-8265.
United States Court of Appeals,
Eleventh Circuit.
March 19, 1999.
Appeal from the United States District Court for the Middle District of Georgia. (No. 5:94-CV-345-3(CWH)),
Claude W. Hicks, Jr., Judge.
Before COX, CARNES and HULL, Circuit Judges.
HULL, Circuit Judge:
Plaintiff-Appellant Kimberly Campbell appeals the magistrate judge's grant of summary judgment
for Defendants on her medical-treatment and excessive-force claims under 42 U.S.C. § 1983. After review,
we affirm.
I. FACTS1
On May 28, 1991, Plaintiff-Appellant Kimberly Campbell was transferred to the Georgia Women's
Correctional Institution ("GWCI") to serve five years of a ten-year sentence for distribution of cocaine and
interference with government property. Plaintiff's constitutional claims arise from the medical treatment she
received at the GWCI state prison between May 28, 1991, and January 30, 1992.
A. Mental Health Treatment
The day Plaintiff arrived at GWCI, she was seen by physician Grant Carmichael, who noted that
Plaintiff had a history of suicidal threats and had taken psychotropic drugs previously at the Cobb County
jail. Carmichael referred Plaintiff to the mental health staff for a mental status exam.
1
The magistrate judge devoted 43 pages of a 102-page order to giving a detailed summary of Plaintiff's
treatment at GWCI. Rather than reiterating the same details, we give only an overview of the facts,
highlighting a few representative occurrences of Plaintiff's self-destructive behavior and Defendants'
various responses.
That same day, Plaintiff met with mental health counselor Anne Weathers for a mental status exam.
Weathers obtained from Plaintiff extensive details about her psychiatric history, including prior medications,
hospitalizations, treatments, and symptoms, and she prepared a three-page report summarizing her
observations and findings.
Weathers's report first details Plaintiff's own descriptions of her history of alcohol and drug use.
Plaintiff admitted using drugs on and off since age thirteen and drinking excessively—as much as a half pint
of liquor a day and a quart of beer a day. The report indicates that Plaintiff used marijuana at first, then beer,
Valium, and ultimately "cocaine/crack."
Weathers's report then focuses on Plaintiff's psychiatric history. Plaintiff told Weathers that while
in school, she received mental health services for "problems with nerves" but no medications. Plaintiff also
reported having a "nervous breakdown" at age eighteen, being hospitalized for a month and a half, receiving
Valium, and having a seizure. After release from the hospital, Plaintiff received services in a day hospital
for several months. She continued to have problems with nerves and panic attacks, and she got Darvon and
Valium from friends to help her cope with these problems. Plaintiff related two suicidal incidents to
Weathers: at age nineteen, Plaintiff cut her wrist superficially, and at age twenty-two, she took an overdose
of lithium in the presence of her husband's son.2
Weathers's report next turns to Plaintiff's treatment at the Cobb County jail after she was arrested on
the cocaine offense. Plaintiff told Weathers that while in the jail, she became anxious, was panicky, heard
loud bells ringing in her head, began to sweat, and felt claustrophobic. Plaintiff reported that she was seen
by a psychologist and received lithium, Stelazine, Mellaril and Benadryl. According to Plaintiff's account,
2
In the district court, Plaintiff introduced medical records showing that between 1982 and 1988, she
had been hospitalized thirteen different times seeking treatment for depression, mood swings, suicide
attempts, anxiety, paranoia, sleep disturbances, and substance abuse. Although these records show
Plaintiff was treated with various medications, including Stelazine and lithium, they show no diagnosis of
bipolar disorder—the diagnosis Plaintiff contends Defendants should have made.
2
she received mental health care in the jail because she told jail officials she was thinking of harming herself.
Plaintiff reported that the last four days at the jail, she had not received any medications.
Weathers's report states that she contacted the Cobb County jail and confirmed that Plaintiff had
received the above medications at the jail and that when she left their facility she was taking Trilafon. The
jail also advised that Plaintiff was intoxicated upon admission to the jail, was unstable and began taking off
her clothes, and made statements about self injury. The jail placed her on suicidal precaution. Weathers's
report relates that the jail officials believed Plaintiff's suicide threats were a "manipulative ploy" because the
jail was reducing her medication:
They said that off and on throughout the stay that she did make statements about intent to harm
herself, but that it was noted that it appeared to be a manipulative ploy in that they were reducing her
medication to stabilize her. They did not consider that she was making a serious suicide threat;
however, they did place her on suicide watch on several occasions as a precaution.
Weathers's report also contains Weathers's own observations from interviewing Plaintiff. According
to the report, Plaintiff's memory was intact for recent and remote events, and there was no evidence Plaintiff
was responding to hallucinations. While denying "delusions and grandiose ideation," Plaintiff reported being
anxious, described a fear of being out of control, and requested to see a doctor to be placed on medication
"to help her rest." Weathers's report concludes with the following recommendation that Plaintiff be seen by
a psychiatrist:
Ms. Campbell reports a history of panic attacks and anxiety related symptoms. She also gives a
history of suicidal thoughts and manipulative suicidal acts. At the present time, she denies intent to
harm herself and signs of anxiety. As she was taking medication while in the Cobb County jail it is
recommended that she be seen by Dr. Sikes to evaluate the need for continuing medication and to
make recommendation for treatment.
Dr. James Sikes, a psychiatrist, met with Plaintiff on June 3, 1991. Before the meeting, he reviewed
Weathers's report, which he noted specified that Plaintiff had been prescribed psychotropic drugs lithium and
Trilafon at the Cobb County jail. Sikes noted, too, that Plaintiff had related a long history of intravenous use
of cocaine as well as heavy alcohol consumption. His report states that the intermittent anxiety and
psychiatric hospitalizations in Weathers's report appeared to arise from complications with drugs and
3
medication. Moreover, Sikes noted that Plaintiff denied having any schizophrenic episodes, auditory
hallucinations, or delusional thoughts.
At the meeting with Plaintiff, Sikes observed Plaintiff's current condition. He found her to be calm
and cooperative. He saw no evidence of delusional thought or loosening of associations. After meeting with
Plaintiff and reviewing Weathers's report, Sikes directed that Plaintiff's Trilafon be discontinued.
Sikes scheduled a follow-up session with Plaintiff for July 1 in order to observe her behavior once
she had been off Trilafon for a few weeks. Sikes's report from that meeting notes the absence of any reported
problems up to that point. The report also states that at the interview, Plaintiff told Sikes she had experienced
trouble sleeping and "what she consider[ed] as normal adjustment to the prison." Sikes suggested increased
activity but reported "no evidence of a schizophrenic illness."
Sikes met with Campbell again on August 12. His reports from that meeting indicate he diagnosed
Plaintiff as suffering from polysubstance abuse arising from her prior alcohol and drug abuse. Sikes also
noted that Plaintiff was "angry and resentful of being called up to talk about things" and that she would
probably "continue to clash with authoritative figures." His thoughts on Plaintiff's condition remained
unchanged: "I see no indication of schizophrenia or Bipolar Disorder and will continue to see her as needed
should further concerns occur." Sikes found no indications of schizophrenia (a thought disorder) or bipolar
disorder (a mood disorder) because Plaintiff showed "no looseness of associations, no evidence of delusional
thought"; he explained, "this seems to be a failure to adjust to the conditions of incarceration rather than a
presence of a psychiatric illness." Sikes concluded that psychotropic medication should not be prescribed
absent a diagnosis of mental illness. According to Sikes's reports, he did not prescribe psychotropic
medication because he diagnosed Plaintiff as suffering from polysubstance abuse and not a mental illness.
Sikes and other mental health professionals met with Plaintiff numerous times in the months ahead.
Sikes himself saw Plaintiff sixteen times: June 3, July 1, August 12, September 4 or 6, 18, 20, 23, 25, and
30, October 9 and 25, November 1, 8, and 25, December 6, and January 29. In mid-September, when
4
Plaintiff's behavior began to deteriorate, Sikes reported, "It appears that this woman 'acts strangely' to get
attention or perhaps to earn additional privileges or perhaps to avoid prosecution for her various
disciplinaries." He recommended establishment and enforcement of clear rules in order to aid Plaintiff in
learning to respect and obey authority. Sikes was confident of Plaintiff's capability to conform her behavior
to institutional rules. He thus explained, "She has a temper as many inmates do but she should be held
accountable for whatever rules she breaks." During each meeting with Plaintiff, Sikes continued to find no
evidence of a psychiatric illness justifying treatment with medication.
Other members of the mental health staff also met with Campbell and reached similar conclusions.
Plaintiff was placed on the caseload of mental health counselor Valarie Ford. Ford met with Plaintiff
thirty-four times between August 1991 and January 1992: August 1, September 16, 17, 19, 20, 23, 24, 26,
and 27, October 10, 14, 15, 16, 21, 22, 23, 24, 25, 27, 28, and 29, November 4, 6, 13, and 19, December 4,
5, 6, 7, 8, 10, 11, and 18, and January 14. Ford reports that she also saw Campbell informally almost every
day during that time period. According to Ford, from the time of the first meeting she perceived Campbell's
behavior as manipulative and saw no evidence of psychosis.
After her first meeting with Plaintiff, Ford referred Plaintiff to Psychologist Dr. Archer Moore, who
also met with Plaintiff on August 1. Moore's report from that meeting states Plaintiff was "a very angry
young woman who denie[d] any thought of hurting herself." Moore found "good reality contact" but "strong
narcissistic features." During Plaintiff's stay at GWCI, Moore saw her six times total (August 1, September
5, 19, 26, and October 10 and 14), and he believed she suffered from a "Narcissistic Personality Disorder"
and not a mental illness but stressed that he considered Plaintiff to be primarily Sikes's patient.
No one on the GWCI staff ever diagnosed Plaintiff as suffering from bipolar disorder or prescribed
psychotropic medications. Instead, the GWCI staff attributed Plaintiff's behavior to the lingering effects of
her prior substance abuse, the difficulties of adjusting to life in prison, and, on some occasions, deliberate
attempts to manipulate officials.
5
B. Restraints
During June, July, and August 1991, Plaintiff was sanctioned a few times for minor disciplinary
infractions. In September 1991, however, Plaintiff began engaging in defiant behavior that eventually became
violent, self-destructive, and even suicidal. On several occasions, she thrashed about her cell, climbed up on
the sink, ripped her sheets to shreds, beat on and dismantled the overhead light, and attempted to obtain sharp
objects. Plaintiff also bit and scratched prison officials and threatened to "hurt someone." Plaintiff often
threatened to flood the toilet, which posed a security risk because it could mandate evacuation of other cells
in the unit. In addition, Plaintiff started multiple fires in her cell, burning her food tray, her Bible, her
clothing, and other such items. One clothing fire she started caused her entire cellblock to be evacuated.
Prison officials responded by removing potentially harmful belongings, instituting terms of solitary
confinement, and restraining Plaintiff using several forms of restraint. Officials gradually increased the level
of restraint. They used straightjackets on several occasions, which made Plaintiff's hands unusable but left
her able to walk around the cell. On at least one occasion when officials used only a straightjacket, Plaintiff
began banging her head and kicking. When Plaintiff's behavior escalated, officials also used "four-point
restraints" at least five times, anchoring each of her arms and legs to a different point on the bed.
Throughout her stay at GWCI, Plaintiff demonstrated an uncanny ability to escape from most forms
of restraint. She removed her straightjacket on numerous occasions, and at least once, she freed herself from
four-point restraints.
Plaintiff's complaint, however, focuses mainly on the instances in which officials employed a third
method of restraint that left her in an "L" shape3 with her knees bent so that her calves were perpendicular
to her back. To use this form of restraint, officials first immobilized Plaintiff's hands and arms using either
a straightjacket or handcuffs behind her back. Next, they put handcuffs on her ankles. Finally, they used a
3
Plaintiff calls it "hog-tying," and Defendants call it "tethering." We refer to it as the "L" shape
method of restraint.
6
strap that ran the length from the handcuffs on her ankles up to the handcuffs on her wrists. This left Plaintiff
in an "L" shape, with her body from her head to her knees defining the vertical part of the "L" and the lower
portion of her legs—from her knees along her calves to her feet—defining the horizontal portion of the "L."
This "L" shape restraint would have resulted in Plaintiff's being in a kneeling position had she been left
upright. Most of the time, she was lying on her side with the "L" shape on a plane parallel to the ground. On
at least one occasion, Plaintiff freed herself from the leg tether while this "L" shape form of restraint was
being used.
Although Plaintiff entered GWCI in May 1991, Sikes first ordered Plaintiff restrained using this "L"
shape method on September 18, 1991. On September 17, Plaintiff was observed standing on the bed with
a sheet wrapped around the back of her neck. Believing Plaintiff might be trying to commit suicide, mental
health staff removed her clothing and other belongings, placed her in seclusion, conducted security checks
every fifteen minutes, and monitored her condition using a camera.
The next morning, Plaintiff was sent to Sikes for evaluation. She yelled at Sikes, turned over a table,
and broke a phone. When Plaintiff was returned to seclusion and ordered to strip in front of male guards, she
refused. Upon a second request, she complied but began running around the cell, kicking and butting the
wall. Officials then contacted Sikes, who ordered Plaintiff placed in a straightjacket, which immobilized her
hands and arms. Shortly thereafter, Plaintiff began banging her head and kicking. When informed of this
behavior, Sikes ordered that Plaintiff be placed in a helmet and that the "L" shape restraint be employed. This
immobilized her legs as well as her arms, preventing her from jumping, climbing, kicking, and running
around the cell.
Between September 18 and October 28, officials restrained Plaintiff using this "L" shape method five
times.4 In addition to the twenty-seven hours on September 18 to 19, the "L" shape restraints were applied
4
Plaintiff actually alleges "at least five times." Undisputed facts include five clear instances of the "L"
shape restraint and other times when the exact type of restraint used is unclear.
7
for about one hour and twenty-five minutes on September 22, five hours on October 12 to 13, sixteen hours
on October 23 to 24, and sixty-six hours and forty minutes on October 25 to 28.5
Although the restraints undoubtedly caused physical discomfort and emotional pain, they
undisputedly caused Plaintiff no physical injury. It is also undisputed that officials monitored Plaintiff's
physical condition while she was restrained. Plaintiff's circulation was checked each time the "L" shape
method of restraint was applied, and security officers checked her every fifteen minutes while she was
restrained. Medical staff also provided regular checks; a nurse assessed Plaintiff's condition every few hours,
and a doctor reevaluated the need for restraints every twenty-four hours.
On at least two occasions, Defendant Sikes declined to approve restraints requested by other officials.
Plaintiff admits that on each of these occasions, Sikes explained to the requesting officers that restraints were
inappropriate when Plaintiff did not pose an immediate threat to her own safety.
Although used five times between September 19 and October 28, the "L" shape restraints were not
used during November and December 1991 or January 1992. Plaintiff asserts the "L" shape restraints were
discontinued because a prison deputy commissioner had issued an edict proscribing "hogtying."
C. Outside Evaluations
In December 1991, Plaintiff requested to be taken off the mental health caseload. The staff conferred
and determined that Plaintiff did not have an Axis I diagnosis and that she would still have a counselor and
5
Although we describe only the first use of the "L"shape restraint, the magistrate judge's order details
all five occurrences and Plaintiff's violent and often self-destructive behavior precipitating the use of the
"L" shape restraint. The approximate periods of the "L" shape restraint are (1) from 10:05 a.m. on
September 18 to 1:05 p.m. on September 19; (2) from 10:20 p.m. to 11:45 p.m. on September 22; (3)
from 9:45 p.m. on October 12 to 2:45 a.m. on October 13; (4) from 10:05 p.m. on October 23 to 2:15
p.m. on October 24; (5) from 3:30 p.m. on October 25 to 10:10 a.m. on October 28.
During these periods of restraint, Campbell was reevaluated every twenty-four hours and
left in restraints only if her self-injurious inclinations were still apparent. For example, restraints
were continued during the longest (almost 67-hour) period of restraint because Campbell
threatened to drink Clorox if the restraints were removed.
8
access to mental health services as needed in the general population. Thus, they granted her request and
reassigned her to the general population on December 31.
On January 28, 1992, Plaintiff was placed in four-point restraints for setting four fires and breaking
the lights in her cell. On January 29, Plaintiff wrapped torn strips from her jumpsuit around her neck in an
attempted suicide. The next day officials sent her to a forensic mental health unit at Central State Hospital
for additional psychiatric evaluation. Doctors there diagnosed Plaintiff as suffering from bipolar disorder and
prescribed the psychotropic medications lithium and Mellaril.
Plaintiff was returned to GWCI for the remainder of her incarceration. Because Sikes was no longer
working at GWCI, Plaintiff was evaluated by Dr. Richard Panico, who had just begun working as a part-time
consulting psychiatrist at GWCI. Dr. Panico diagnosed Plaintiff as suffering from bipolar disorder and
prescribed lithium.
Plaintiff was paroled in March 1993. After her release, Plaintiff was admitted to Georgia Regional
Hospital in February 1994. The Georgia Regional Hospital records indicate that the February admission was
due to "a serious overdose on lithium" and that Plaintiff had "a past history of suicidal threats."
Plaintiff was admitted again to Georgia Regional Hospital for reevaluation and treatment on April
28, 1994. At this admission, psychological testing was done to aid in evaluating Plaintiff. The Georgia
Regional Hospital records reveal that Plaintiff was diagnosed as presenting a "personality disorder," "with
borderline anti-social features, and an Axis I diagnosis of alcohol and substance abuse." At Georgia Regional
Hospital, the treating psychiatrist specifically noted that "Plaintiff did not present an Axis I diagnosis of
bipolar disorder."
II. PROCEDURAL HISTORY
A. Complaint
Plaintiff filed a complaint in state court in nine counts: (1) a § 1983 claim for deliberate indifference
to serious medical needs; (2) a § 1983 claim for cruel and unusual punishment through use of stripping,
9
restraint, and isolation; (3) a § 1983 claim for excessive force; (4) a § 1983 substantive-due-process claim
for punishment in lieu of treatment; (5) a § 1983 claim alleging infringements of Plaintiff's
procedural-due-process and First Amendment rights; (6) a claim under the Georgia Tort Claims Act
("GTCA") for medical and professional negligence; (7) a GTCA claim for intentional infliction of emotional
distress; (8) a GTCA claim for negligence and intentional infliction of emotional distress against Sikes and
Moore as independent contractors; and (9) a claim alleging violations of the Georgia Constitution and a
Georgia statute regarding types of punishment. The five defendants in Plaintiff's initial complaint were the
Georgia Department of Corrections ("GDOC"), Mental Health Director Albert Duncan, Psychiatrist James
Sikes, Psychologist Archer Moore, and Warden Art Gavin.
Defendants removed to federal court in the Northern District of Georgia. In federal court, Plaintiff
filed her first amended complaint, which incorporates the claims in the initial complaint and adds Mental
Health Counselor Valarie Ford as a Defendant. The district court granted Plaintiff's motion to amend.
The district court also granted in part Plaintiff's motion to remand to state court, remanding all claims
against the GDOC and any official-capacity claims against Duncan, Sikes, Moore, Gavin, and Ford. Thus,
remaining in federal court were Plaintiff's individual-capacity claims against Duncan, Sikes, Moore, Gavin,
and Ford.
B. Motions for Summary Judgment
After Defendants' motion for a transfer to the federal court in the Middle District of Georgia was
granted, the parties consented to proceeding before a magistrate judge and began discovery. Defendants filed
separate motions for summary judgment, arguing Plaintiff had failed to allege a constitutional violation and
asserting qualified immunity.
C. Magistrate Judge's Order
On January 28, 1998, the magistrate judge issued an order (1) granting Defendants Sikes, Moore,
Gavin, and Ford summary judgment based on qualified immunity on all five of Plaintiff's § 1983 claims; (2)
10
granting those Defendants summary judgment on any Georgia Tort Claims Act claims still in federal court;
and (3) with Plaintiff's consent, dismissing Duncan as an improper party.
D. Scope of This Appeal
Plaintiff's appeal challenges only the magistrate judge's grant of summary judgment on her § 1983
claims against Defendants Sikes, Moore, Gavin, and Ford. Plaintiff does not appeal the dismissal of
Defendant Duncan or the grant of summary judgment for Defendants on any Georgia Tort Claims Act claims
remaining in federal court. Plaintiff also abandons certain constitutional violations alleged in her first
amended complaint. She primarily focuses on two distinct alleged violations of the Eighth Amendment: (1)
Defendants' deliberate indifference to serious medical needs, and (2) Defendants' excessive force.
Thus, on appeal, we discuss whether the magistrate judge erred in granting summary judgment for
Defendants Sikes, Moore, Gavin, and Ford on Plaintiff's § 1983 claims for deliberate indifference to serious
medical needs and for use of excessive force.6
III. REVIEW OF SUMMARY JUDGMENT BASED ON QUALIFIED IMMUNITY
We review the magistrate judge's grant of summary judgment de novo. Steele v. Shah, 87 F.3d 1266,
1269 (11th Cir.1996). In doing so, we "evaluate the summary judgment record in the light most favorable
to ... the nonmovant," and we will affirm the district court's grant of summary judgment only if the record
demonstrates that there was no genuine issue of material fact and that Defendants were entitled to judgment
as a matter of law. Id.; Fed.R.Civ.P. 56.
The magistrate judge's order and the parties' briefs focus almost exclusively on qualified immunity
and the question of whether, at the time of Defendants' actions, the law clearly established that Plaintiff's
rights were being violated. We turn first to an alternate basis for summary judgment, inquiring whether this
record contains any evidence of an underlying constitutional violation. Because Plaintiff's evidence would
6
To the extent that Plaintiff appeals other claims and issues, we find no reversible error in the decision
of the magistrate judge. See 11th Cir. Rule 36-1.
11
not support a reasonable jury's finding that Defendants violated Plaintiff's constitutional rights, we need not
address the applicability of qualified immunity. See Killian v. Holt, 166 F.3d 1156 (11th Cir.1999) (affirming
district court's entry of summary judgment for defendants without qualified immunity analysis because
plaintiff "failed to bring forth evidence from which reasonable jurors could find that defendant prison officials
knew of and were deliberately indifferent to a substantial risk of serious harm"); Hale v. Tallapoosa County,
50 F.3d 1579, 1582 (11th Cir.1995) (affirming summary judgment for one defendant without relying on
qualified immunity because the plaintiff's evidence was "insufficient to support the level of deliberate
indifference and causal connection necessary");7 see also Cottrell v. Caldwell, 85 F.3d 1480, 1489-92 (11th
Cir.1996) (in an interlocutory appeal of the district court's denial of summary judgment, turning first to
plaintiff's evidence of the constitutional violation itself and holding, "plaintiff has failed to show a violation
of due process, and it necessarily follows that the defendants are entitled to summary judgment on qualified
immunity grounds"); Adams v. Poag, 61 F.3d 1537 (11th Cir.1995) (in another interlocutory appeal of a
district court's denial of summary judgment, holding defendants were entitled to summary judgment based
on qualified immunity because plaintiffs had failed to present evidence of deliberate indifference to support
their Eighth Amendment claim).8
IV. EIGHTH AMENDMENT
7
See also Crawford-El v. Britton, 523 U.S. 574, 118 S.Ct. 1584, 1586, 140 L.Ed.2d 759 (1998) (noting
that when a claim requires "proof of wrongful motive," it may be preferable to begin summary judgment
analysis by examining the proof of intent because "the immunity question ... sometimes requires
complicated analysis of legal issues").
8
We observe that this case—unlike Cottrell and Adams—is an appeal from a final judgment, where
there is no dispute that we can examine first whether there is sufficient evidence to support a reasonable
jury's finding a constitutional violation. However, Cottrell and Adams show that even in interlocutory
appeals limited strictly to qualified immunity issues, the same procedure is permissible. In another
qualified immunity interlocutory appeal, Dolihite v. Maughon, 74 F.3d 1027 (11th Cir.) cert. denied, ---
U.S. ----, 117 S.Ct. 185, 136 L.Ed.2d 123 (1996), this Court again focused on the "predicate element of
the underlying constitutional tort," which is "part and parcel of the core qualified immunity issue which is
immediately appealable." Id. at 1033 n. 3. Even if identification of the precise knowledge of each
defendant is not "part and parcel of the core qualified immunity issue," it is " 'inextricably intertwined'
with the core issue and thus would be immediately appealable." Id.12
The Eighth Amendment governs the conditions under which convicted prisoners are confined and
the treatment they receive while in prison. Farmer v. Brennan, 511 U.S. 825, 832, 114 S.Ct. 1970, 128
L.Ed.2d 811 (1994) (quoting Helling v. McKinney, 509 U.S. 25, 31, 113 S.Ct. 2475, 125 L.Ed.2d 22 (1993));
see also Whitley v. Albers, 475 U.S. 312, 327, 106 S.Ct. 1078, 89 L.Ed.2d 251 (1986) (holding that "the Due
Process Clause affords ... no greater protection"). Although the Constitution does not require comfortable
prisons, it does not permit inhumane ones. Farmer, 511 U.S. at 832, 114 S.Ct. 1970 (quoting Rhodes v.
Chapman, 452 U.S. 337, 349, 101 S.Ct. 2392, 69 L.Ed.2d 59 (1981)). Still, the Eighth Amendment does not
authorize judicial reconsideration of "every governmental action affecting the interests or well-being of a
prisoner," Whitley, 475 U.S. at 319, 106 S.Ct. 1078; instead, " '[a]fter incarceration, only the " 'unnecessary
and wanton infliction of pain' "... constitutes cruel and unusual punishment forbidden by the Eighth
Amendment.' " Id. at 319, 106 S.Ct. 1078 (quoting Ingraham v. Wright, 430 U.S. 651, 670, 97 S.Ct. 1401,
51 L.Ed.2d 711 (1977) (quoting Estelle v. Gamble, 429 U.S. 97, 103, 97 S.Ct. 285, 50 L.Ed.2d 251 (1976)
(citations omitted))).
Crucial to establishing an "unnecessary and wanton infliction of pain" is some proof that officials
acted with specific intent. This specific-intent requirement for an Eighth Amendment violation applies to
both failure to provide proper medical care, Steele v. Shah, 87 F.3d 1266, 1269 (11th Cir.1996), and excessive
force, see Whitley, 475 U.S. at 319-21, 106 S.Ct. 1078. However, the exact nature of the specific intent
required depends on the type of claim at issue. Whitley, 475 U.S. at 319, 106 S.Ct. 1078. Thus, we address
each claim in turn.
V. "DELIBERATE INDIFFERENCE" TO SERIOUS MEDICAL NEEDS
The Eighth Amendment's proscription of cruel and unusual punishments prohibits prison officials
from exhibiting deliberate indifference to prisoners' serious medical needs. Estelle v. Gamble, 429 U.S. 97,
104, 97 S.Ct. 285, 50 L.Ed.2d 251 (1976). The Supreme Court has been careful to note, however, that "a
complaint that a physician has been negligent in diagnosing or treating a medical condition does not state a
13
valid claim of medical mistreatment under the Eighth Amendment." Id. at 106, 97 S.Ct. 285. Thus, in Estelle
v. Gamble, which first enunciated the "deliberate indifference" standard, the Supreme Court reinstated the
district court's dismissal of a prisoner's § 1983 complaint for failure to state a claim. Noting that the
complaint's primary allegation was that "more should have been done" to diagnose and treat a back injury,
the Court explained, "A medical decision not to order an X-ray, or like measures, does not represent cruel and
unusual punishment. At most it is medical malpractice." Id. at 107, 97 S.Ct. 285.
Subsequent Supreme Court cases have refined the inquiry. In Wilson v. Seiter, 501 U.S. 294, 111
S.Ct. 2321, 115 L.Ed.2d 271 (1991), the Supreme Court explained that the Eighth Amendment applies only
to punishments and that prison conditions are only punishment if a mental element of punitive intent is
shown:
The source of the intent requirement is not the predilections of this Court, but the Eighth Amendment
itself, which bans only cruel and unusual punishment. If the pain inflicted is not formally meted out
as punishment by the statute or the sentencing judge, some mental element must be attributed to the
inflicting officer before it can qualify.
Id. at 300, 111 S.Ct. 2321. Although the very imposition of a certain term in prison is punitive, the punitive
purpose of the sentence itself does not convert every attribute of the place of incarceration into a punishment
subject to Eighth Amendment scrutiny. Thus, conditions of confinement violate the Eighth Amendment only
if they (1) rise to the level of a "serious" deprivation; and (2) result from the official's "deliberate
indifference." Id. at 297-99, 111 S.Ct. 2321. Wilson and subsequent cases refer to these two required
elements as an "objective component" scrutinizing the alleged deprivation and a "subjective component"
examining the official's mental intent.
A. Farmer v. Brennan Requires Proof Of Subjective Mental Intent
Most recently, in Farmer v. Brennan, 511 U.S. 825, 114 S.Ct. 1970, 128 L.Ed.2d 811 (1994), the
Supreme Court explained further the requisite "subjective component" of a conditions-of-confinement claim
and defined the exact subjective mental state required for "deliberate indifference," as follows:
14
[A] prison official cannot be found liable under the Eighth Amendment for denying an inmate
humane conditions of confinement unless the official knows of and disregards an excessive risk to
inmate health or safety; the official must both be aware of facts from which the inference could be
drawn that a substantial risk of serious harm exists, and he must also draw the inference. This
approach comports best with the text of the Amendment as our cases have interpreted it. The Eighth
Amendment does not outlaw cruel and unusual "conditions"; it outlaws cruel and unusual
"punishments." An act or omission unaccompanied by knowledge of a significant risk of harm might
well be something society wishes to discourage, and if harm does result society might well wish to
assure compensation. The common law reflects such concerns when it imposes tort liability on a
purely objective basis. But an official's failure to alleviate a significant risk that he should have
perceived but did not, while no cause for commendation, cannot under our cases be condemned as
the infliction of punishment.
Id. at 837-38, 114 S.Ct. 1970 (emphasis added) (internal citation omitted). Thus, in light of Farmer, liability
may be imposed for deliberate indifference only if the plaintiff proves the defendant actually knew of "an
excessive risk to inmate health or safety" and disregarded that risk. Id. at 837, 114 S.Ct. 1970. Proof that
the defendant should have perceived the risk, but did not, is insufficient. Id. at 838, 114 S.Ct. 1970; Cottrell
v. Caldwell, 85 F.3d 1480, 1491 (11th Cir.1996) ("There is no liability for 'an official's failure to alleviate a
significant risk that he should have perceived but did not ....' " (quoting Farmer, 511 U.S. at 838, 114 S.Ct.
1970)). Thus, the official must have a subjectively " 'sufficiently culpable state of mind.' " Cottrell, 85 F.3d
at 1491 (quoting Farmer, 511 U.S. at 834, 114 S.Ct. 1970). This "requirement follows from the principle that
'only the unnecessary and wanton infliction of pain implicates the Eighth Amendment.' " Farmer, 511 U.S.
at 834, 114 S.Ct. 1970 (quoting Wilson, 501 U.S. at 297, 111 S.Ct. 2321).
B. Post-Farmer Decisions
This Court recently applied Farmer in the psychiatric medical needs context in Steele v. Shah, 87
F.3d 1266 (11th Cir.1996). In Steele, a Florida inmate claimed that a prison psychiatrist was deliberately
indifferent in discontinuing prescribed psychotropic medication. The Steele Court explained that under
Farmer, summary judgment must be granted for the defendant official unless the plaintiff presents evidence
of the official's subjective knowledge, as follows:
since a finding of deliberate indifference requires a finding of the defendant's subjective awareness
of the relevant risk, Farmer v. Brennan, 511 U.S. 825, 837-38, 114 S.Ct. 1970, 1979, 128 L.Ed.2d
811 (1994), a genuine issue of material fact exists only if the record contains evidence, albeit
15
circumstantial, Farmer, 511 U.S. at 842, 114 S.Ct. at 1981, of such subjective awareness. See
Cottrell v. Caldwell, 85 F.3d 1480, 1491 (11th Cir.1996) (acknowledging Farmer's requirement of
subjective awareness and rejection of a solely objective test of deliberate indifference).
Id. at 1269 (emphasis added).
This subjective knowledge was evidenced in Steele by the underlying facts and circumstances of the
case. The plaintiff had been prescribed psychotropic medications at a previous institution. Id. at 1267. When
the plaintiff was transferred to a new prison, the defendant, Dr. Shah, saw the plaintiff for "less than one
minute" and discontinued psychotropic medications. Id. Shah did not review any medical records other than
the Treatment Plan listing medications prescribed by the prior institution, and he did not consult with any
medical staff. Id. After Shah discontinued the plaintiff's medication, medical staff from the prior institution
wrote the new prison expressing concern that the plaintiff was a suicide risk, had been on psychotropic
medication, and was not now receiving his medication. Id. at 1268. Their letters clarified that the plaintiff
had been diagnosed as having "Adjustment Disorder with Anxious Mood," needed psychotropic medication,
had tried suicide twice, and was considered a suicide risk. Id. at 1267-68. Still, Shah did not respond; the
plaintiff continued without psychotropic medication for the duration of his time at the new prison. Id.
This Court held that a jury would be entitled to find that Shah had discontinued the plaintiff's
medication "on the basis of one cursory interview and without having reviewed any medical records beyond
the Treatment Plan sent over from the Polk facility." Id. at 1270. The Court continued that a jury could
further find that Shah " 'knew of a substantial risk from the very fact that the risk was obvious,' " that Shah
"deliberately disregarded that risk," and that Shah "was aware from Polk personnel that Steele was considered
by them to be a potential suicide risk, and that that was one basis for their prescription of the psychotropic
drugs." Id. (quoting Farmer, 511 U.S. at 842, 114 S.Ct. 1970).
The Steele Court noted that this circuit's two most directly relevant precedents both pre-dated Farmer.
Id. at 1269 n. 2 (citing Greason v. Kemp, 891 F.2d 829 (11th Cir.1990); Waldrop v. Evans, 871 F.2d 1030(11th Cir.1989)). However, the Steele Court found that Farmer did not necessarily affect the holdings in
16
those two preFarmer cases, stating "Greason (surely) and Waldrop (almost as surely) based their specific
holdings on the existence of evidence of subjective awareness." Id. We understand Steele 's equivocation
about Waldrop 's holding because Waldrop discusses only what a reasonable person would have known—an
objective test.9 However, we do examine Greason in detail because Steele relies so heavily on Greason.10
In Greason, the inmate's prior therapist at Gwinnett County Mental Health Center had sent a letter
to the prison doctor describing the inmate's current mental status, relating his history of mental illness, and
noting that he had been hospitalized thirteen times and diagnosed as a "schizophrenic" with suicidal
tendencies. Id. at 831-32. The therapist urged continuation of the inmate's medication for his diagnosed
mental illness and close monitoring. Id. The inmate's psychiatrist at the Georgia Department of Human
Resources also sent a letter reporting that the inmate continued to have suicidal thoughts and needed to be
maintained on his medication. Id. at 832. Both letter reports were in the inmate's clinical file. Id.9
Waldrop never addresses whether there is sufficient evidence for a reasonable jury to find the
defendants knew their case was grossly inadequate. Instead, Waldrop inquires whether there is evidence
that the defendants' actions were grossly incompetent and violated professional standards, and it focuses
on what a reasonable person in the defendants' position would have known. Waldrop, 871 F.2d at 1034-
36. Thus, Steele was correct in hesitating to rely on Waldrop 's assessment of the evidence now that
Farmer has clarified the subjective-intent requirement. Steele, 87 F.3d at 1269 n. 2. Like the Steele
Court, we focus instead on Greason.
10
We question Steele 's characterization of Greason as basing its holding on evidence of subjective
awareness. Greason is a pre-Farmer case that does not purport to apply the Farmer subjective prong.
Instead, Greason examines the evidence of deliberate indifference in the context of an objective qualified
immunity analysis. Although Greason does state, "we believe that a trier of fact could find that Dr. Fodor
provided such care [grossly inadequate psychiatric care] and, moreover, that he realized that he was doing
so at the time," id. at 835, the ultimate holding in Greason is that "a jury could find (1) that Dr. Fodor
provided grossly inadequate care and (2) that a reasonable person in Dr. Fodor's position would have
known that the care delivered constituted deliberate indifference to Greason 's Eighth Amendment
rights." Id. (emphasis supplied).
Nonetheless, we are not required to resolve whether Steele correctly characterizes
Greason 's holding, the precedential effect of Steele 's statements about and reliance on pre-
Farmer, Greason, or whether the facts of Greason would have met the Farmer test because, in
any event, Greason 's facts are readily distinguishable from those in this case.
17
Two and a half months after the inmate's arrival, the prison psychiatrist saw him for a few minutes,
promptly concluded that his condition had stabilized, and discontinued his medications without reviewing
the clinical file or assessing his mental status to determine his potential for suicide. About a month later, the
psychiatrist saw the inmate again for only a few minutes.11 Based on these facts, the Greason Court found
that there was sufficient evidence from which a jury could conclude that the psychiatrist provided grossly
inadequate medical care "and, moreover, that he realized that he was doing so at the time." Id. at 835
(emphasis supplied).
The parties also cite other post-Farmer Eleventh Circuit decisions involving deliberate indifference
to an arrestee's or an inmate's non-psychiatric medical needs. See, e.g., Lancaster v. Monroe County, Ala.,
116 F.3d 1419, 1426-27 (11th Cir.1997) (involving a chronic alcoholic dying from a withdrawal-induced
seizure while in pretrial detention after his wife warned jailers about his chronic alcoholism and propensity
for life-threatening seizures as he withdraws, directly applying Farmer, and holding sufficient evidence
presented from which a jury could find that each defendant "knew [the decedent] had urgent medical needs
that would be significantly exacerbated by delay," that each defendant "planned to keep [the decedent] in jail
without medical supervision or treatment until he had a seizure," and each defendant "delayed obtaining
treatment for [the decedent] until after he suffered a seizure"); Cottrell v. Caldwell, 85 F.3d 1480, 1490-91
(11th Cir.1996) (involving an arrestee dying from positional asphyxia while in a police car, directly applying
Farmer, and holding no evidence to support a jury finding that defendant police officers "were consciously
aware of and disregarded the risk that [decedent arrestee] would suffocate" as a result of defendants'
positioning and restraining decedent arrestee in police car); Adams v. Poag, 61 F.3d 1537, 1543-48 (11th
Cir.1995) (involving inmate with acute asthma and inability to breathe, reversing the denial of qualified
11
Later, the inmate's parents visited the inmate in prison and reported to an assistant who worked under
the psychiatrist's supervision that the inmate had suicidal thoughts. Fearing the inmate might attempt
suicide again, the parents urged the assistant to have the inmate transferred to a hospital. The assistant did
nothing and did not contact the psychiatrist. Twenty-four days later, the inmate hung himself. Id. at 832-
33.
18
immunity, and holding that evidence created fact issues regarding medical malpractice but not deliberate
indifference).12 Although helpful guidance, these three decisions do not involve deliberate indifference to
psychiatric medical needs. Thus, we have focused instead on Steele and Greason, which do.13
C. Plaintiff's Contentions
We now apply the teachings of Farmer, Steele, and Greason to this case. Plaintiff contends that
Defendants' medical care was grossly inadequate and that Defendants knew their care was grossly inadequate.
According to Plaintiff, the medical care Defendants provided was grossly inadequate because Defendants
misdiagnosed her as having a polysubstance abuse disorder when they knew or should have known she had
bipolar disorder, discontinued medication that would have treated her bipolar disorder, improperly used
behavior modification techniques, and waited eight months before sending her outside the prison for
12
Although post-Farmer, Adams does not cite or discuss Farmer, but it nonetheless stresses that in this
Circuit "cases have consistently held that knowledge of the need for medical care and an intentional
refusal to provide that care constitutes deliberate indifference." 61 F.3d at 1543 (emphasis supplied).
13
The parties also cite this Court's post-Farmer decisions in Dolihite v. Maughon, 74 F.3d 1027 (11th
Cir.1996), and Hale v. Tallapoosa County, 50 F.3d 1579 (11th Cir.1995). However, we focus on Steele
as it involves the subjective element of deliberate indifference (as opposed to the objective qualified
immunity analysis in Dolihite ) and psychiatric medical needs (as opposed to inmate-on-inmate violence
in Hale ), and we discuss Greason because of Steele 's reliance on it.
Dolihite concerns a juvenile who hung himself while involuntarily civilly committed at a
state psychiatric facility, but the majority opinion does not cite Farmer or discuss the subjective
prong outlined in Farmer. Instead, the majority opinion in Dolihite addresses only the objective
prong of qualified immunity—whether "a reasonable professional in defendant's shoes would
have known that his challenged actions (or inaction) violated plaintiff's constitutional rights." Id.
at 1046.
In Hale, the plaintiff arrestee sued for damages arising from being beaten by other
occupants of an overcrowded, small "bullpen" with detainees not segregated based on proclivity
for violence or reasons for confinement. 50 F.3d at 1580-81. The case turned on whether
defendants knew about the significant risk of inmate-on-inmate violence but knowingly
disregarded that risk and kept the plaintiff arrestee in that bullpen. Id. at 1582-84. The Court
stressed the evidence that officials admitted knowing that inmate-on-inmate violence occurred in
that overcrowded "bullpen" on a regular basis and resulted in injuries requiring medical
treatment. Id. at 1583.
19
diagnostic tests. Plaintiff also submits expert testimony stating Defendants' medical care was grossly
inadequate, while Defendants' experts state Defendants complied with the applicable standard of care.
After review, we agree with the magistrate judge that Plaintiff has presented insufficient evidence
for a reasonable jury to find that Defendants knew that she had bipolar disorder, that Defendants knew they
had misdiagnosed her as suffering from polysubstance abuse rather than bipolar disorder, or that Defendants
otherwise knew their treatment was grossly inadequate but proceeded with the treatment anyway. Without
evidence to establish the subjective mental intent prong of deliberate indifference, Defendants are entitled
to summary judgment under Farmer. We address Plaintiff's evidence against each Defendant in turn.
D. Defendant Sikes
Defendant Sikes is a psychiatrist who worked part time at GWCI. Sikes first met with Plaintiff on
June 3, 1991, a few days after her transfer to GWCI, and he gave the order to discontinue her psychotropic
medication. Sikes himself saw Plaintiff sixteen times during the eight months before he determined that she
needed to go to Central for further mental health examination. Sikes was also consulted by mental health staff
on numerous other occasions, and he was repeatedly called upon to advise correctional officers on how to
respond to Plaintiff's self-destructive behavior.
Sikes's liability turns on whether he knew Plaintiff had bipolar disorder, or knew he was
misdiagnosing Plaintiff, or knew his treatment was otherwise grossly inadequate but proceeded with the
treatment anyway. Sikes's reports show he diagnosed Plaintiff as suffering from polysubstance abuse, and
Plaintiff agrees that psychotropic medication is not proper treatment for polysubstance abuse. Plaintiff's
complaint asserts principally that Sikes misdiagnosed her condition, that she had bipolar disorder rather than
merely suffering from polysubstance abuse, that her behavior made it obvious that she had bipolar disorder,
and that Sikes should have known both that she was bipolar and that medication was the proper treatment for
bipolar disorder. In addition, Plaintiff argues any treatment she did receive was both grossly inadequate and
detrimental to her bipolar condition.
20
1. Facts Regarding Sikes's Treatment
Sikes is entitled to summary judgment on Plaintiff's deliberate-indifference claim because Plaintiff
failed to present evidence from which a reasonable jury could infer that Sikes knew she had bipolar disorder,
or knew he was misdiagnosing Plaintiff, or knew his treatment was otherwise grossly inadequate but
proceeded with the treatment anyway. See Steele, 87 F.3d at 1269; Greason, 891 F.2d at 835. Turning first
to the initial diagnosis and discontinuation of medication, the undisputed evidence shows that Sikes
discontinued Plaintiff's medication only after Sikes personally interviewed Plaintiff and reviewed a three-page
report by Weathers, who had performed an extensive review of Plaintiff's history and symptoms.14 It is also
undisputed that Sikes, unlike the psychiatrists in Steele and Greason, conducted multiple follow-up sessions
and observed Plaintiff's behavior repeatedly once she was off medication; altogether, he met with Campbell
sixteen times. Moreover, Weathers's report revealed the Cobb County jail told Weathers that Campbell's
suicidal threats might be an attempt to manipulate officials as they were reducing her medication. In stark
contrast, the professionals previously responsible for the plaintiff inmates in Steele and Greason stressed the
inmates' suicidal tendencies and prior psychiatric diagnoses and urged continued medication.
Plaintiff faults Sikes for not obtaining and reviewing her actual medical records from the Cobb
County jail or her prior thirteen hospitalizations as a juvenile. However, Sikes reviewed (a) Weathers's
detailed summary of Weathers's communications with the Cobb County jail, which included an account of
Campbell's symptoms and treatment at the jail, and (b) Weathers's summary of Plaintiff's personal history,
which included an account of mental health problems as a juvenile and a prior hospitalization. Moreover,
the jail records and prior hospitalization records themselves, which are in evidence in this case, contain no
diagnosis of bipolar disorder.
14
Sikes says he also performed an independent review of Plaintiff's history, but Plaintiff disputes that.
We thus rely only on Sikes's personal interview of Campbell and his review of Weathers's report.
21
Plaintiff also points to the fact that Sikes did know she was prescribed Trilafon and lithium while at
the Cobb County jail, which she says should have put Sikes on notice she had bipolar disorder. However,
the Cobb records themselves show Plaintiff was placed on Trilafon and lithium without indicating a diagnosis
of bipolar disorder. Indeed, in an affidavit, Dr. Youngleson, who prescribed the medication at the jail,
testifies (1) that Plaintiff was never given any diagnosis while at the jail; (2) that looking back, he believes
Plaintiff suffered from a personality disorder rather than bipolar disorder; and (3) that Plaintiff's threats and
self-destructive behavior seemed manipulative. The jail records also show Cobb County jail officials'
concerns that Plaintiff might be "running a game on us" and acting out to manipulate officials.
Sikes's ongoing medical treatment is also readily distinguishable from that in Steele and Greason,
where the psychiatrists basically did nothing to treat the inmates after discontinuing their medication. See
Adams v. Poag, 61 F.3d 1537, 1544 (11th Cir.1995) (noting that "when the need for medical treatment is
obvious, medical care that is so cursory as to amount to no treatment at all may constitute deliberate
indifference"). In stark contrast, Sikes spent a great deal of time and effort working with Plaintiff. Sikes also
recommended mental health counseling, consistent with his stated diagnosis that Plaintiff suffered from
polysubstance abuse.15 In addition, Sikes had other medical staff members monitor Plaintiff's behavior and
symptoms, and he took affirmative steps to prevent Plaintiff from harming herself and others. Such actions
readily distinguish Sikes's care from the deliberate indifference in Steele and Greason.16
2. Expert Testimony
Lacking direct or circumstantial factual evidence to establish or to allow a jury to infer Sikes's
knowledge, Plaintiff attempts to create a factual issue regarding Sikes's mental intent by submitting opinion
testimony by medical experts. In affidavits and depositions, Plaintiff's experts testify that given Plaintiff's
15
As noted above, Plaintiff was placed on the caseload of mental health counselor Valarie Ford. Ford
conducted 34 counseling sessions with Plaintiff and saw Plaintiff informally on a near daily basis.
16
Such actions also readily distinguish this case from the deliberate refusal to give the pre-trial arrestee
any medical treatment in Lancaster v. Monroe County, Ala., 116 F.3d 1419, 1426-27 (11th Cir.1997).
22
prior hospitalizations and medication and her symptoms and behavior, Sikes should have known that Plaintiff
had bipolar disorder and needed medication and that Sikes's treatment was grossly inadequate. In response,
Defendants present expert testimony opining that Defendants' medical care fully complied with the applicable
standards of care and that reasonable mental health professionals could have reached the same conclusions
Defendants reached and taken the same actions Defendants took. Plaintiff's experts' opinion testimony
directly contradicts that of Defendants' experts.
The question becomes whether the opinion testimony by Plaintiff's experts here creates a jury issue
regarding Defendants' subjective mental intent required by Farmer. More specifically, the issue is this: since
the facts and circumstances of this case do not allow an inference that Sikes not only should have perceived
the risk but also actually did perceive it, does the opinion testimony by Plaintiff's medical experts based on
those same facts and circumstances provide the missing Farmer link? The answer is no.
We begin by examining our precedent for guidance. This circuit has not discussed directly the
precise role of expert testimony in a post-Farmer decision turning on the subjective mental intent of medical
professionals sued for deliberate indifference to an inmate's serious psychiatric medical needs. Neither Steele
nor Greason relies on opinion testimony by medical experts as evidence that the psychiatrist knew his care
was grossly inadequate. In Steele the plaintiff presented no expert testimony at all,17 and in Greason this
Court relied on expert testimony only in addressing the objective prong of deliberate indifference.18 Instead,
17
Indeed, another issue before the Steele Court was whether the district court had erred in refusing to
appoint an expert witness to assist the plaintiff. 87 F.3d at 1271. The Court remanded for the district
court to reconsider appointing an expert, noting that "the appropriate standard of psychiatric care" was at
issue and that "[e]xpert opinion on that issue and its application here obviously might be important to the
finder of fact." Id.; see also Young v. City of Augusta, 59 F.3d 1160, 1169-70 (11th Cir.1995) (upholding
the district court's decision not to appoint an expert to assist plaintiff Young because "[t]he presence of a
genuine issue of fact with respect to deliberate indifference to Young's medical needs is apparent from the
face of the record" without any expert testimony).
18
Greason relies on expert testimony in listing what the defendant psychiatrist would have known had
he reviewed the inmate's file before discontinuing medication: there was testimony by a psychiatrist "that
Greason possessed a great number of the characteristics associated with a high suicide risk." 891 F.2d at
835 n. 11. It also relies on expert testimony "that Greason received grossly inadequate care," and it
23
the egregious facts and circumstances in those cases created the requisite factual issue of deliberate
indifference or wanton conduct.
The parties rely heavily on this Court's treatment of expert affidavits in Dolihite v. Maughon, 74 F.3d
1027 (11th Cir.1996). However, like Greason, Dolihite considers expert medical affidavits only in relation
to the objective inquiry of qualified immunity—whether a reasonable medical professional in the defendants'
position would have known that the defendants' actions violated the juvenile's constitutional rights.19 Dolihite
acknowledges that in the unique context of a claim of deliberate indifference to medical needs, expert
testimony is relevant to ascertaining the applicability of qualified immunity:
Our circuit has indicated that the testimony of medical experts can aid the court in determining
whether qualified immunity is appropriate where allegations hinge upon the appropriateness of the
actions of medical professionals, including mental health professionals.
Id. at 1046. Dolihite does not address the role of expert testimony in determining whether a plaintiff has
sufficient evidence of the subjective mental intent required for a jury finding of deliberate indifference to
serious medical needs under Farmer. Indeed, the majority opinion in Dolihite does not even cite Farmer.
Moreover, Dolihite 's explanation for considering expert testimony is particular to the objective qualified
immunity inquiry:
Such expert medical testimony, making reference to specific deficiencies in a defendant's treatment
and specific medically accepted standards might, in conjunction with the specific facts of a case,
persuade a court that the medical defendant's actions in the case were clearly as great a departure
from appropriate medical standards as previous departures found unconstitutional in prior cases—i.e.,
might persuade a court that a reasonable professional in defendant's shoes would have known that
his challenged actions (or inaction) violated plaintiff's constitutional rights.
Id. at 1046. Thus, Dolihite 's consideration of expert testimony in applying qualified immunity's objective
standard does not answer our question about the role of expert opinion testimony when applying Farmer 's
subjective-intent requirement.
reaffirms a past case's holding that "the conflict among the experts concerning the propriety of the
psychiatrist's professional judgment calls [must] be resolved by the jury." Greason, 891 F.2d at 835.
19
See footnote 13 supra.
24
In two other conditions-of-confinement cases since Farmer, the plaintiffs failed to create triable
issues regarding the defendants' subjective mental intent. Each opinion lends support to our ultimate
conclusion regarding expert testimony, but admittedly neither is squarely on point here. In Cottrell v.
Caldwell, 85 F.3d 1480 (11th Cir.1996), this Court held that the plaintiff's expert affidavit regarding what
"was well known by police" was insufficient to create a jury issue regarding Farmer 's subjective component.
Id. at 1491. The Court explained that "such a conclusory statement about police in general is not evidence
about the mental state of these defendant officers in particular." Id. Although helpful guidance on the role
of expert testimony, Cottrell does not fully answer the question here for two reasons. First, Cottrell involves
expert affidavits about police officers' positioning and restraining arrestees in police cars, as opposed to expert
medical testimony. Also, Cottrell appears to rely in part on the conclusory nature of the affidavits, and not
all the testimony Plaintiff presents in this case is so conclusory.
Similarly, in Adams v. Poag, 61 F.3d 1537, 1543-48 (11th Cir.1995), this Court examined the
plaintiff's expert testimony and found it failed to create a triable issue regarding the defendants' subjective
intent. However, as noted above, Adams is framed in terms of qualified immunity and does not cite Farmer.20
Moreover, Adams, too, seems to rest on particular deficiencies in the wording of the affidavits at
issue-deficiencies that are present in a great deal of, but not all, the testimony Plaintiff relies on in this case.
Lastly, in Hale v. Tallapoosa County, 50 F.3d 1579 (11th Cir.1995), a post-Farmer inmate-on-inmate
violence case, we considered experts' opinions, but only where other factual evidence showed the defendant
sheriff's actual knowledge. Considering all the evidence, we found a triable issue as to whether the defendant
possessed the subjective mental intent required by Farmer. Id. at 1583. Importantly, however, our finding
of a factual issue did not rest on expert testimony alone. Although we noted the expert's testimony that "given
the conditions in the months preceding [the attack], it was plainly foreseeable to a reasonable law enforcement
official that a violent attack was likely to occur," we also stressed the defendant's own admission "that he
20
See footnote 12 supra.
25
knew that inmate-on-inmate violence was occurring on a regular basis" and "that he knew the violence
sometimes resulted in injuries requiring medical treatment." Id.
Lacking a controlling application of Farmer 's standard, we turn to Farmer itself. In Farmer, the
Supreme Court made clear that the subjective mental intent prong requires that the official actually know of
a substantial risk of serious harm to the inmate's health and then disregard that risk. Farmer, 511 U.S. at 837,
114 S.Ct. 1970. An "official's failure to alleviate a significant risk that he should have perceived but did not,
while no cause for commendation, cannot ... be condemned as the infliction of punishment." Id. at 838, 114
S.Ct. 1970. Under Farmer, proof that the defendant should have perceived the risk but did not is insufficient.
Id. at 838, 114 S.Ct. 1970. Farmer also explains:
When instructing juries in deliberate indifference cases with such issues of proof, courts should be
careful to ensure that the requirement of subjective culpability is not lost. It is not enough merely
to find that a reasonable person would have known, or that the defendant should have known, and
juries should be instructed accordingly.
Id. at 843 n. 8, 114 S.Ct. 1970. Instead, the plaintiff must submit evidence that the medical professional
defendant actually was aware of the significant risk of serious harm but deliberately proceeded with grossly
inadequate treatment anyway.
The issue of subjective mental intent under Farmer is different from whether Sikes's medical
treatment was negligent or grossly inadequate. To decide the issue of subjective mental intent under Farmer,
a jury would inquire (1) whether Sikes was aware of facts about Plaintiff from which he could draw the
inference that his present course of treatment presented a substantial risk of serious harm to Plaintiff and (2)
whether he actually drew that inference but persisted in the course of treatment anyway. There is no direct
or circumstantial evidence in this record from which the jury could infer Sikes's actual knowledge, and
Plaintiff's experts' testimony does not provide the missing link under Farmer—at least under the facts and
circumstances of this case. Indeed, allowing expert testimony that Sikes should or would have known to raise
a jury issue as to whether he actually knew effectively would nullify Farmer's requirement of subjective
mental intent. The deficiency of the expert testimony here arises not necessarily from the specific wording
26
of the experts' testimony—although some of Plaintiff's affidavits are lacking in many respects21—but from
the inherent opinion nature of expert testimony about what a person should or would have known. The
particular conflicting expert testimony here demonstrates only that there is a difference of opinion among
professionals about what is accepted practice within the psychiatric community and what a doctor should or
21
While we do not rely on deficiencies in the wording of the expert affidavits, we do note a few of
their shortcomings. For example, the experts' testimony contains many conclusory statements that
Defendants were deliberately indifferent that do not govern our assessment of the evidence. See Dolihite,
74 F.3d at 1046-47 & n. 33 (explaining that "an expert opinion which is merely conclusory, even if
couched in the language of the relevant legal standard, will be of little assistance to a court"); Cottrell, 85
F.3d at 1491 ("[A] conclusory statement about police in general is not evidence about the mental state of
these defendant officers in particular."); Rogers v. Evans, 792 F.2d 1052, 1062 n. 9 (11th Cir.1986)
(holding that an affidavit "phrased in conclusory terms" was "defective to create a factual dispute").
In addition, some of the affidavits rest on false factual predicates. For instance, the
opinion of James S. Cheatham, M.D., seems to rely in part on the assumption that Plaintiff had
been diagnosed as suffering for bipolar disorder prior to entering GWCI. Neither the Cobb
County jail records nor the other medical records in evidence contain a prior diagnosis of bipolar
disorder.
Also, of the expert affidavits Plaintiff presents, the principal affidavit that opines about
what medical professionals would know is by John R. Paddock, who has a Ph.D. in psychology.
Dr. Paddock reviews the behavior Defendants observed and the treatment they implemented and
states, "Any person with professional credentials in the area of mental illness or the treatment of
mental or emotional disorders would know that what the Defendants were doing was grossly
improper in design, approach, and implementation." In certain areas, such as prescribing
medicine, the training of psychologists and psychiatrists is not equivalent; thus, Dr. Paddock is
not a competent expert to testify to what a psychiatrist like Sikes would know about the need to
prescribe medicine.
Finally, there is the opinion statement of Kenneth I. Robbins, M.D. that Sikes's own
testimony "demonstrates he knew his behavior was improper." However, Sikes's testimony itself
either does or does not prove knowledge. Dr. Robbins's opinion about what Sikes's testimony
shows is not probative. Moreover, Sikes's testimony, that Dr. Robbins refers to here, does not
demonstrate that Sikes knew his behavior was improper. What Dr. Robbins is referring to here is
that Sikes testified restraints were only to be used in limited situations and that Sikes left his
patient in restraints over a weekend. Dr. Robbins concludes from Sikes's testimony about the
limited use of restraints that Sikes knew leaving Plaintiff in restraints over a weekend was
improper. However, Dr. Robbins fails to note the undisputed evidence that other psychiatrists
were on call that weekend, that they were available to answer correctional officers' questions, and
that they were called upon every twenty-four hours to reassess the continued need for restraints.
Thus, Sikes's testimony does not create a factual issue regarding Sikes's knowledge that his care
was grossly inadequate—nor does Dr. Robbins's opinion about Sikes's testimony.
27
would know. Plaintiff's experts' testimony here at best allows an inference by the jury that a doctor should
have perceived the risk of serious harm but not an inference that the doctor actually did perceive the risk and
persisted in his course of treatment anyway.22
Of course, rarely if ever will a defendant medical professional admit that he knew his course of
treatment was grossly inadequate but proceeded with that treatment anyway. Therefore plaintiffs necessarily
must use circumstantial evidence to establish subjective mental intent. See Farmer, 511 U.S. at 842, 114
S.Ct. 1970; Lancaster v. Monroe County, 116 F.3d 1419, 1426 (11th Cir.1997); Steele, 87 F.3d at 1269.
But expert opinion testimony is not essential to that task. For example, in both Steele and Greason,
the plaintiffs created triable issues regarding the defendants' knowledge without any expert opinion testimony
by presenting evidence of the particular facts and circumstances in those cases.23 As noted above, the doctor
in Steele stopped Steele's medication after a "less than one minute" meeting and without reviewing medical
22
We located one post-Farmer circuit court decision squarely addressing whether expert medical
testimony can create a factual issue about subject mental intent in cases involving deliberate indifference
to serious medical needs. In McKee v. Turner, No. 96-3446 (6th Cir. Aug.25, 1997), the Sixth Circuit
held the defendant psychiatrist was entitled to summary judgment because there was no evidence showing
that the psychiatrist had acted with deliberate indifference. The expert's affidavit stated that the defendant
psychiatrist had departed from accepted standards of medical care and that the risk of suicide "must have
been obvious" to the defendant psychiatrist. The Sixth Circuit held that this affidavit was insufficient to
support a finding of deliberate indifference, stressing that under Farmer, "the official's conduct is judged
by what he actually knew, not by what a reasonable person in his shoes would have known." The Sixth
Circuit concluded:
The issue here is not whether Dr. Morcos committed medical malpractice, but rather
whether Dr. Morcos had knowledge or facts about [Plaintiff] from which he could draw
the inference that his present course of treatment presented a substantial risk of serious
harm to [Plaintiff], and that he actually drew that inference, but persisted in the course of
treatment anyway. There is nothing in the record demonstrating this.
124 F.3d at 198; see also Williams v. Mehra, 135 F.3d 1105 (6th Cir.), vacated and set for reh'g
en banc, 144 F.3d 428 (6th Cir.1998).
23
See also Lancaster v. Monroe County, 116 F.3d 1419, 1426-29 (11th Cir.1997) (finding defendants'
own testimony regarding their knowledge and other evidence that the defendants were personally warned
of the detainee's condition created triable issues regarding defendants' subjective mental intent without
any expert testimony).
28
records. More importantly, the doctor proceeded with no medication in the face of warnings from the prior
institution that the plaintiff was a suicide risk, had tried suicide twice, and needed psychotropic medication.
The doctor's conduct was similar in Greason: he saw Greason for a few minutes, promptly concluded that
Greason's condition had stabilized, and discontinued Greason's medications without reviewing the clinical
file or assessing Greason's mental status to determine his potential for suicide. The letters in the clinical file
showed Greason was a schizophrenic, had suicidal tendencies, and needed medication. In both Greason and
Steele, this Court relied on facts and circumstances that made the risk of grossly inadequate care and suicide
so obvious that a jury could infer the defendants' actual knowledge. In contrast, here there was no prior
diagnosis of bipolar disorder, and the jail officials advised that they did not consider Plaintiff's suicide threats
to be serious and that they perceived Plaintiff's aberrant behavior as an attempt to manipulate officials.
Because Plaintiff has not presented sufficient direct or circumstantial evidence to create a factual
issue regarding Sikes's subjective mental intent and the experts' opinion testimony here does not provide the
missing link, we affirm the magistrate judge's decision to grant Sikes summary judgment on Plaintiff's
deliberate-indifference claim.
E. Defendant Moore
Defendant Moore was a licensed psychologist who worked one day a week at GWCI.24 Unlike
Sikes, Moore could not prescribe medication. Moreover, because Moore worked at GWCI only one day a
week, his duties and responsibilities were decided week by week on an as-needed basis. Moore saw Plaintiff
six times between August and October 1991. His last contact with Plaintiff was on October 24, 1991.
Plaintiff has failed to present sufficient evidence for a reasonable jury to find Moore knew that
Plaintiff had bipolar disorder or that his treatment was grossly inadequate. Moore diagnosed Plaintiff as
having a personality disorder, as opposed to a mental illness, and Plaintiff has presented no evidence that
Moore knew his diagnosis was incorrect. Plaintiff's primary contention is that Moore should have performed
24
On December 7, 1998, Moore's counsel filed notice that Moore had died on November 22, 1998.
29
psychological tests even though Sikes did not order them. Again, Plaintiff presents expert testimony about
Moore's care, which might establish Moore breached the standard of care and was negligent but does not
support a finding that Moore knew Plaintiff was misdiagnosed and needed medication or knew his care was
otherwise inadequate.25 Without evidence of Moore's subjective intent, Plaintiff's deliberate-indifference
claim cannot succeed.
F. Defendant Ford
Defendant Ford is a mental health counselor, untrained in diagnosing mental illness and unauthorized
to prescribe medication. Plaintiff was assigned to Ford for counseling during most of the eight-month period
in question. Ford had almost daily contact with Plaintiff.
Plaintiff focuses on two alleged deficiencies in the care Ford provided. First, Plaintiff points to an
October 1991 memorandum Ford wrote to prison security personnel instructing that they impose maximum
disciplinary penalties for Plaintiff's infractions of prison rules. The memorandum states that Plaintiff had
received seventeen prior disciplinary reports, that Plaintiff had been evaluated several times by Drs. Moore
and Sikes, that Plaintiff "does not currently have an Axis I diagnosis," and that therefore "[t]he current
treatment goal for Ms. Campbell as recommended by Dr. Sikes and the mental health staff is behavior
modification."
There is no evidence to support a jury finding that by writing the security memorandum Ford was
deliberately indifferent to Plaintiff's serious medical needs. First, the memorandum also states that "[m]edical
staff will be responsible for ensuring that medical needs are met according to policy." Second, Plaintiff has
presented no evidence that Ford knew Plaintiff suffered from bipolar disorder—much less that Ford knew
Plaintiff's self-destructive and defiant behavior stemmed from bipolar disorder. Moreover, Ford wrote this
memorandum at Sikes's direction, acting on the express instructions of a medical doctor who was trained in
25
Some of the expert testimony about Moore's care seems to rest on the erroneous assumption that
Moore's knowledge about Plaintiff was commensurate with Sikes's. However, as with Sikes, we do not
rely on particular deficiencies in the affidavits.
30
diagnosis of mental illness, had diagnosed Plaintiff with polysubstance abuse and not bipolar disorder, and
had recommended behavior modification treatment as opposed to medication.
Second, Plaintiff faults Ford for the overnight "delay in treatment" once it had been determined that
Plaintiff needed to go to Central for further evaluation. It is undisputed that on the night of January 29, Ford
knew it had been determined that Plaintiff should be sent to Central. It is also undisputed that officials
secured Plaintiff in four-point restraints overnight and sent her to Central the next morning. Plaintiff alleges
that it was Ford's decision to delay the transfer and that Ford decided to apply four-point restraints without
a prior order from a medical doctor.26
Again, however, Plaintiff has presented no evidence that Ford knew that Plaintiff had bipolar disorder
or that such overnight delay amounted to grossly inadequate care. Dr. Paddock's affidavit purports to support
a finding that Ford "had to know" the care Plaintiff received was grossly inadequate:
Defendant Ford was in a position and exercising responsibility in which she would have had to know
that further and additional mental health/psychological evaluation and assessment of Ms. Plaintiff
were required by her and consistent with the competencies of other members of the treatment team
(e.g., licensed psychologists and psychiatric physicians), and that the acts undertaken were grossly
deficient.
As discussed regarding Sikes, this expert affidavit does not suffice to support a finding that Ford knew her
care was grossly inadequate but persisted in that treatment. At best, it might support a finding that Ford's care
was grossly inadequate or a finding that Ford should have known or perceived—or "had to know"—her care
was grossly inadequate. However, as explained above, "[t]here is no liability for 'an official's failure to
alleviate a significant risk that he should have perceived but did not....' " Cottrell v. Caldwell, 85 F.3d 1480,
1491 (11th Cir.1996) (citing Farmer, 511 U.S. at 838, 114 S.Ct. 1970).
G. Defendant Gavin
26
According to Plaintiff, the medical doctor's order approving the four-point restraints used on this
occasion was signed almost two months later on March 24, 1991.
31
Plaintiff acknowledges that Defendant Gavin, the GWCI warden, was not employed as a mental
health professional. Plaintiff claims only that Gavin was deliberately indifferent in supervising others who
were deliberately indifferent to her serious medical needs. By its own terms, Plaintiff's claim against Gavin
cannot succeed without evidence of an underlying constitutional violation by one of the mental health
professionals. As explained above, the record contains no such evidence. Thus, Gavin is necessarily entitled
to summary judgment on this claim.27
VI. EXCESSIVE FORCE
Plaintiff also claims that even if Defendants' actions did not amount to deliberate indifference to her
serious medical needs, their use of restraints constituted excessive force.
A. Proof Required that Force Used Maliciously and Sadistically to Cause Harm
The Eighth Amendment's proscription of cruel and unusual punishments also governs prison
officials' use of force against convicted inmates. See Whitley v. Albers, 475 U.S. 312, 327, 106 S.Ct. 1078,
89 L.Ed.2d 251 (1986) (holding that "the Due Process Clause affords [convicted prisoners] no greater
protection than does the Cruel and Unusual Punishments Clause"). To establish an Eighth Amendment claim
for excessive force, however, Plaintiff must meet an intent requirement more stringent than Farmer 's
deliberate-indifference standard: she must prove that "force was applied ... maliciously and sadistically for
the very purpose of causing harm." Whitley, 475 U.S. at 320-21, 106 S.Ct. 1078 (quoting Johnson v. Glick,
481 F.2d 1028, 1033 (2d Cir.1973)); see also Hudson v. McMillian, 503 U.S. 1, 6-7, 112 S.Ct. 995, 117
L.Ed.2d 156 (1992).
Discussing this heightened specific-intent requirement in Whitley, the Supreme Court reiterated that
force does not violate the Eighth Amendment merely because it is unreasonable or unnecessary: "The
infliction of pain in the course of a prison security measure ... does not amount to cruel and unusual
punishment simply because it may appear in retrospect that the degree of force authorized or applied for
27
Plaintiff's supervisory liability claim against Sikes fails for the same reason.
32
security purposes was unreasonable, and hence unnecessary in the strict sense." 475 U.S. at 319, 106 S.Ct.
1078. Reviewing the force used to quell a prison riot in Whitley, the Court explained that "whether the
measure taken inflicted unnecessary and wanton pain and suffering ultimately turns on 'whether force was
applied in a good faith effort to maintain or restore discipline or maliciously and sadistically for the very
purpose of causing harm.' " Id. at 320-21, 106 S.Ct. 1078 (quoting Johnson, 481 F.2d at 1033).
Subsequently, in Hudson v. McMillian, 503 U.S. 1, 112 S.Ct. 995, 117 L.Ed.2d 156 (1992), the
Supreme Court extended Whitley 's holding outside the prison-riot context and applied the same heightened
intent requirement to force used as a prophylactic, preventive measure. See Whitley, 475 U.S. at 322, 106
S.Ct. 1078 (acknowledging the distinction). The Hudson Court held that "whenever prison officials stand
accused of using excessive physical force in violation of the Cruel and Unusual Punishments Clause, the core
judicial inquiry is that set out in Whitley: whether force was applied in a good-faith effort to maintain or
restore discipline, or maliciously and sadistically to cause harm." Id. at 6-7, 112 S.Ct. 995. The Court
reasoned that even absent the exigency present during a riot-like disturbance, " ' "[p]rison administrators ...
should be accorded wide-ranging deference in the adoption and execution of policies and practices that in
their judgment are needed to preserve internal order and discipline and to maintain institutional security." '
" Hudson, 503 U.S. at 7, 112 S.Ct. 995 (quoting Whitley, 475 U.S. at 321-22, 106 S.Ct. 1078 (quoting Bell
v. Wolfish, 441 U.S. 520, 547, 99 S.Ct. 1861, 60 L.Ed.2d 447 (1979))). Thus, Hudson dictates that Whitley
's standard—force applied maliciously and sadistically to cause harm—applies to all claims that prison
officials used excessive force against convicted prisoners.
In addition to defining the mental state required, Hudson and Whitley outline five distinct factors
relevant to ascertaining whether force was used "maliciously and sadistically for the very purpose of causing
harm": (1) "the extent of injury"; (2) "the need for application of force"; (3) "the relationship between that
need and the amount of force used"; (4) "any efforts made to temper the severity of a forceful response";
and (5) "the extent of the threat to the safety of staff and inmates, as reasonably perceived by the responsible
33
officials on the basis of facts known to them." Whitley, 475 U.S. at 321, 106 S.Ct. 1078; see also Hudson,
503 U.S. at 7, 112 S.Ct. 995. Whitley also narrows the precise inquiry applicable when deciding whether
officials are entitled to judgment as a matter of law:
courts must determine whether the evidence goes beyond a mere dispute over the reasonableness of
a particular use of force or the existence of arguably superior alternatives. Unless it appears that the
evidence, viewed in the light most favorable to the plaintiff, will support a reliable inference of
wantonness in the infliction of pain under the standard we have described, the case should not go to
the jury.
Whitley, 475 U.S. at 322, 106 S.Ct. 1078 (emphasis added).
B. Eleventh Circuit Applications
Plaintiff's excessive-force claim focuses on restraints Defendants used while she was in isolation.
Thus, we review prior decisions of this Court applying Whitley to uses of restraints and isolation.
Affirming summary judgment in Williams v. Burton, 943 F.2d 1572 (11th Cir.1991), this Court held
that the officials' using four-point restraints and a gag was not excessive force. Officials placed Williams in
four-point restraints, with gauze and tape over his mouth, for twenty-eight and one-half hours. Id. at 1574.
There were only brief intervals for eating, physical exercise, and toilet use. Id. Noting that Williams had
threatened to kill officials, spat on them, and thrown bodily fluids at them, this Court explained that the
four-point restraints and gag were not excessive force but were used to prevent Williams from harming
himself or officials:
[t]he four-point restraints were used to reduce or eliminate Williams' ability to inflict physical harm
against either himself or the correction officers. The restraints were not used for the purpose of
inflicting pain. The gauze padding and tape were used to prevent Williams from encouraging further
unrest among the other inmates in the segregation unit, as well as to protect the officers from his
continuing spital assault.
Id. at 1575. Also important to the Williams decision were the observations (1) that although the inmate
"experienced some discomfort because of his restraint, no actual injury was inflicted" id.; and (2) that
"constant monitoring and examinations by medical personnel" were adequate to safeguard the inmate's
well-being. Id.34
Williams stresses that courts should afford great deference to prison officials regarding the use of
restraints as a prophylactic or preventive measure, stating:
How long restraint may be continued calls for the exercise of good judgment on the part of prison
officials. Once it is established that the force was applied in a good faith effort to maintain discipline
and not maliciously or sadistically for the purpose of causing harm, the courts give great deference
to the actions of prison officials in applying prophylactic or preventive measures intended to reduce
the incidence of riots and other breaches of prison discipline.
Id. at 1576 (internal citations omitted). This Court also found the officials' "continuous observation and
management of Williams during his restraint" showed their good faith, and we concurred with the district
court's holding that "Williams' history of persistent disobedience and the potential for a disturbance in the
segregation unit justified the continued use of the restraints and gag until the officers were reasonably assured
that the situation had abated." Id.Similarly, in Sims v. Mashburn, 25 F.3d 980 (11th Cir.1994), this Court upheld the officials' use of
a stripped cell for twenty-nine hours and reversed the district court's grant of judgment for the inmate. The
inmate in Sims hung various items over the window to his cell, preventing prison officials from observing
his behavior; he placed a towel in the toilet, which officers took as an implicit threat to flood the segregation
unit; and he threatened that if officials entered his cell, "I'll buck; you'll have to kill me." Id. at 981. On that
basis, officials stripped his cell and removed all clothing except his undershorts, and they disconnected the
water to his toilet. Id. at 981-82.
In determining whether the officials had used good faith or acted "maliciously and sadistically to
cause harm," this Court observed that the officers had followed the prison's operating procedures for stripping
cells, which required, among other things, documenting the incident and checking on the inmate's status every
fifteen minutes. Id. at 985-86. Again, we emphasized that compliance with an established prison policy
evidences an official's good faith, particularly when, as in Sims, "[t]he policy itself reflects a well-developed
and planned procedure." Id. at 986. In the field of prison discipline, "prison officials, not judges, are
experts." Id.35
C. Application To This Case
Plaintiff focuses on the instances in which officials used the "L" shape restraint in addition to the
straightjacket. The record reflects that officials used the "L" shape restraint at least five different times for
periods of twenty-seven hours on September 18 to 19, one hour and twenty-five minutes on September 22,
five hours on October 12 to 13, sixteen hours on October 23 to 24, and sixty-six hours and forty minutes on
October 25 to 28.
As explained above, Plaintiff's excessive-force claim depends on whether these periods of restraint
were instituted "maliciously and sadistically for the very purpose of causing harm." Precedent dictates that
this determination be guided by the five Hudson /Whitley factors outlined above, by deference to prison
officials' punitive judgments, and by this Court's previous holdings that compliance with prison policies
evidences officials' good faith. For several reasons, such considerations convince us that the record here does
not create a factual issue regarding malicious or sadistic intent.
First, the urgent need for force was readily apparent each time the "L" shape restraint was applied;
the undisputed facts show Plaintiff posed a serious threat to herself and to others. Plaintiff not only told
officials that she was considering suicide but also actually took steps toward harming herself on more than
one occasion. When the "L" shape restraint was applied initially in September 1991, officials found her
standing on the bed with a sheet around her neck. As noted above, on other occasions, she thrashed about
her cell, climbed up on the sink, ripped her sheets to shreds, beat on and dismantled the overhead light, and
attempted to obtain sharp objects. Plaintiff also bit and scratched prison officials, and she repeatedly
threatened to "hurt someone." Some of Plaintiff's actions posed a security risk as well. She regularly
threatened to flood the toilet, and she often started fires in her cell, burning such items as her food tray, her
Bible, and her clothing. One clothing fire mandated evacuation of her entire cellblock.
36
Moreover, lesser restraints were ineffective in curbing Plaintiff's dangerous behavior. Plaintiff freed
herself from straightjackets on multiple occasions. In addition, on one occasion when officials used only a
straightjacket, Plaintiff began banging her head and kicking.
Although resulting in physical discomfort and emotional pain, the restraints undisputedly caused
Plaintiff no physical injury. More importantly, the officers carefully monitored Plaintiff's physical condition
while she was restrained. They checked Plaintiff's circulation each time they applied the "L" shape method
of restraint, and security officers checked Plaintiff every fifteen minutes while she was restrained. There were
also regular checks by medical staff, with a nurse evaluating Plaintiff's condition every few hours and a doctor
reassessing the need for restraints every twenty-four hours.
Additionally, the severity of the restraint was tempered somewhat by attention to Plaintiff's basic
physical needs. During periods of restraint, Plaintiff was given "toileting" on request,28 offered meals at
regular intervals, and sometimes given a mattress rather than being made to lie on the floor.
Also evidencing the officials' good faith is their compliance with prison procedures for using
restraints. GWCI policies provide for extensive documentation and monitoring when restraints are used, and
Defendants met and exceeded those requirements. For example, in addition to completing the required
written documentation, Defendants videotaped some of the instances in which they used the "L" shape
restraint.29
In addition, on at least two different occasions, Sikes declined to approve restraints when other
officials requested them. Each time, Sikes instructed the requesting officials that restraints should not be
applied when Plaintiff did not pose a threat to her own safety. Such decisionmaking by Sikes hardly betrays
a malicious or sadistic motive.
28
Plaintiff asserts that there was one instance in which she urinated on herself while in restraints and
the situation was not discovered for some hours.
29
Plaintiff entered in the record before the magistrate judge a videotape of several "L" shape incidents,
and that tape is part of the record on appeal as well.
37
Plaintiff provides no viable reason to depart from the conclusion dictated by these considerations.
Her main contention is that four-point restraints would have been equally effective and less dehumanizing
than the "L" shape. In addition, she points to a deputy prison commissioner's testimony that he was shocked
to hear that prisoners were being "hog-tied." However, such evidence raises "a mere dispute over the
reasonableness of a particular use of force or the existence of arguably superior alternatives," Whitley, 475
U.S. at 322, 106 S.Ct. 1078, and would not suffice to support a jury finding that the officials restrained
Plaintiff in this manner "maliciously and sadistically for the very purpose of causing harm." Id. at 320-21,
106 S.Ct. 1078.
There is also no showing that the "L" shape method of restraint used here violated prison policies.30
Both GDOC and GWCI policies clearly allowed restraints to be used to curb dangerous behavior, and neither
policy forbade this particular method of restraint. GDOC operating procedures merely authorized restraints
"to prevent the inmate from hurting himself or others" and defined "hard restraints" versus "soft restraints."
GDOC Standard Operating Procedure No. VC01-0014 (Revised Oct. 1, 1989).31 Similarly, GWCI policy
authorized restraints as "a temporary means of controlling an inmate's destructive behavior toward herself
and others." GWCI Policy Statement No. 801.1 (activated Nov. 1, 1989; revised June 13, 1991). GWCI
policy also examined the costs and benefits of several different methods of restraint, noting that "[t]he
following comments should be reviewed and considered in making a decision as to which devices to use when
restraint is necessary." Id. The "L" shape method used here was not expressly listed, but GWCI policy
30
It is far from clear in the case law that officials' violating prison policy would necessarily establish
the requisite subjective mental intent. In this case, however, because there is insufficient evidence to
support a finding that prison policies were violated, we need not address whether a violation of prison
policies is per se malicious and sadistic.
31
We refer to the policies in effect when the challenged instances of restraint occurred. There is some
indication in the record that since that time, the policies may have been amended to proscribe "hog-tying."
38
expressly provided in a separate subsection that a physician might "also consider other options as to the
method of restraint most likely to be appropriate." Id.Plaintiff argues that the absence of "hog-tying" from the lists of possible restraint methods meant the
"L" shape method used here was forbidden. In support of that contention, she offers the testimony of a deputy
prison commissioner who interpreted the state operating procedures to ban "hog-tying." However, the deputy
commissioner's testimony is insufficient to create a triable issue in the face of the clear and unambiguous
language of the policies themselves, which did not ban or in any way proscribe this method of restraint but
instead expressly permitted doctors to consider using other methods of restraint.
VII. CONCLUSION
Because we find insufficient evidence to support a jury's finding that any of the Defendants possessed
the subjective mental intent required to support Plaintiff's deliberate-indifference and excessive-force claims,
the magistrate judge's grant of summary judgment for Defendants Sikes, Moore, Gavin, and Ford is
AFFIRMED.
39